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Biosafety Considerations for Autopsy The American Journal of Forensic Medicine and Pathology 23(2):107–122, 2002. ©2002 by Lippincott Williams & Wilkins, Inc., Philadelphia Biosafety Considerations for Autopsy Kurt B. Nolte, M.D., David G. Taylor, Ph.D., and Jonathan Y. Richmond, Ph.D. An autopsy may subject prosectors and others to a wide variety “. .What kind of a cut is it? Where is it?” of infectious agents, including bloodborne and aerosolized “Right here, on my finger. I rode over to the village pathogens such as human immunodeficiency virus, hepatitis B today—you know, the one they brought that and C viruses, and Mycobacterium tuberculosis. Other hazards include toxic chemicals (e.g., formalin, cyanide, and organo- mouzhik with typhus from. For some reason or phosphates) and radiation from radionuclides used for patient other they were getting ready to do an autopsy on therapy and diagnosis. These risks can be substantially miti- him, and it’s been a long time since I’ve had any gated through proper assessment, personal protective equip- practice of that sort.” ment, appropriate autopsy procedures, and facility design. “. .Old timer,” Bazarov began in a hoarse, slow Key Words: Autopsy—Biohazards—Chemical hazards— Toxichazards. voice, “my goose is cooked; I’ve been infected and in a few days you’ll be burying me.” Ivan S. Tur- genev, Fathers and Sons, 1862 Autopsies can be performed with the consent of the next-of-kin of persons who die of natural causes in hospitals, or they can be performed under legislated authority (forensic or medicolegal autopsies) on persons who die of violent, unnatural, suspicious, sudden, or unexplained causes. The frequency of consent autopsies has declined substantially over the previous several de- cades, from approximately 50% of all hospital deaths in 1950 to less than 10% in 1995 (1). One reason for this decline is the potential increased risk of occupational exposure of pathologists to dangerous pathogens (2). With decreased hospital autopsy rates, the proportion of medicolegal postmortem examinations has increased. Medicolegal autopsies constituted a large proportion, and in some jurisdictions the majority, of the total number performed in 1981 (3). Since then, national hospital autopsy rates have continued to decline, and medicolegal autopsies likely represent the majority of these proce- dures performed in almost all areas of the United States. AUTOPSY HAZARDS Manuscript received January 20, 2002; accepted January 20, 2002. From the Office of the Medical Investigator, University of New Mexico School of Medicine, Albuquerque, New Mexico, the Medical Examiner/Coroner Information Sharing Program, Division of Public Infectious Agents Health Surveillance and Informatics, Epidemiology Program Office, The risk of infectious disease transmission has long and Infectious Disease Pathology Activity, Division of Viral and Rick- been recognized for prosectors, observers, and other per- ettsial Diseases, National Center for Infectious Diseases (K.B.N.) and the Office of Health and Safety (D.G.T., J.Y.R.), Centers for Disease sons in close proximity to an autopsy. Retrospective Control and Prevention, Atlanta, Georgia, U.S.A. surveys of British clinical laboratories between 1970 and Address correspondence and reprint requests to Kurt B. Nolte, M.D., 1989 demonstrated that the highest rates of laboratory- Office of the Medical Investigator, University of New Mexico School of Medicine, Albuquerque, NM 87131-5091, U.S.A.; e-mail: knolte@ acquired infections were in autopsy workers (4–8). Au- salud.unm.edu topsy-transmitted infections may occur after direct cuta- 107 108 K. NOLTE ET AL. neous inoculation (percutaneous injury), contact with per exposure (31); and for HCV, an average of 1.8% per droplets, and aerosol exposure. exposure but may be as high as 10% (38,46). Although Pathology residents sustained a percutaneous injury the viability of HIV in cadaveric blood appears to de- with blood exposure in 1 of 11 autopsies and experienced crease over time, this organism has been isolated from pathologists in 1 of 55 autopsies (9). Autopsy prosectors specimens from deceased persons with postmortem in- sustained cuts at twice the frequency that they sustained tervals of 6, 11, and 16 days (47–50). HIV-infected needle punctures (9). Scalpel blades created the majority bodies should be considered infectious for at least 2 of these cuts, resulting in a potentially large inoculum of weeks after death. HBV in the environment is also hardy. infectious agent. However, many other sharp objects HBV in human plasma retained infectivity 1 week after such as broken glass, embedded needle fragments, bone being dried and exposed to an ambient environment (51). shards, and fragmented projectiles can injure autopsy Clearly, the transmission risks for these bloodborne personnel (9–11). In addition, approximately 8% of sur- pathogens, combined with their high seroprevalence in gical gloves are punctured during autopsy, and approxi- certain autopsy populations and the frequency of percu- mately one third of these punctures remain undetected by taneous injury, place autopsy personnel at high risk for the prosector (12). Glove punctures may cause preexist- sustaining an occupational infection. ing hand lesions to be bathed in infectious blood for Performing autopsies on persons who have died of prolonged periods of time. viral hemorrhagic fever (VHF) poses even greater risks. Many infections can be transmitted by direct inocula- Prosectors have died of autopsy-transmitted Marburg, tion. For example, pathologists have died of streptococ- Ebola, and Lassa hemorrhagic fevers (22,26,52,53). cal sepsis after sustaining minor cutaneous injuries dur- These infections have been transmitted by direct cutane- ing autopsies on persons with the same disease (13). ous inoculation. Although aerosol transmission of VHF Other infections that can be transmitted in this manner has been suspected in outbreaks occurring within hospi- include tuberculosis, blastomycosis, coccidioidomycosis, tals (54,55), whether these infections may also be trans- acquired immunodeficiency syndrome, hepatitis B and C mitted via autopsy aerosols is unclear. Lymphocytic cho- (or non-A, non-B), rabies, tularemia, diphtheria, erysip- riomeningitis and yellow fever have been fatally eloid fever, and some of the viral hemorrhagic fevers transmitted to human prosectors, and Rift Valley fever (4,8,14–33). Some of these autopsy-transmitted infec- has been transmitted to prosectors of veterinary case tions have proved to be fatal. material (56–58). None of these persons were reported to Among physicians, pathologists are recognized as a have sustained an injury during dissection. The prosec- high-risk group for occupationally acquired hepatitis B tors in whom Rift Valley fever developed did not wear virus (HBV) because of their exposure to blood (34,35). masks during the procedure. Autopsy aerosols could There are at least two records of autopsy workers who have transmitted these infections. The conditions where died of occupationally acquired hepatitis (8,32). The autopsies are performed are often primitive in most lo- prevalence of HBV, hepatitis C virus (HCV), and human cations where deaths resulting from VHF occur. There- immunodeficiency virus (HIV) infection is higher in fore, the risks and benefits must be carefully considered forensic autopsy populations than in the general public before an autopsy is performed on a person suspected to because of an overrepresentation of intravenous drug have died of one of these conditions (19). Immunohis- abusers among decedents subjected to autopsy (36,37). tochemical procedures on formalin-fixed skin biopsy In some areas of the United States, up to 90% of intra- specimens have proved useful in the diagnosis of Ebola venous drug abusers may be infected with HCV (38). In hemorrhagic fever (52). A skin biopsy can be performed one study of the autopsy population in Baltimore, Mary- more safely and readily than an autopsy, thereby reduc- land, the medical examiner demonstrated an infection ing exposure to infectious materials. However, if the skin seroprevalence of 5.6% for HIV, 23.2% for HBV, and biopsy result is negative and no autopsy has been per- 19.1% for HCV (37). This study did not discriminate formed, definitive diagnosis may be impossible. Autop- between acute and remote HBV infections. Another sies have been performed safely on deceased persons study of a medicolegal cadaver population in Milan, with VHF, using strict safety protocols (59). Similar to Italy, revealed an infection seroprevalence of 16% for the diagnosis of VHF, immunofluorescence and immu- HIV and 29% for HCV (39). Other studies of forensic nohistochemical procedures can be used to detect rabies autopsy populations have identified an HIV seropreva- virus antigen in skin and may obviate the risks associated lence of 2% in Vancouver, Canada (40), 11% in South with an autopsy (60,61). Africa (41), 2.2% in Philadelphia, Pennsylvania (42), Autopsies on persons who died of hantavirus infec- and 1% in Scotland (43). In 1983, 18% of young adults tions appear to pose fewer risks than other VHFs. A who died suddenly in San Francisco had antibodies to study of health care workers (including autopsy prosec- HIV (44). The transmission risk with infected blood for tors) involved in a 1993 hantavirus pulmonary syndrome HIV is 0.3% per exposure (45); for HBV, at least 30% outbreak indicated no evidence of autopsy transmission Am J Forensic Med Pathol, Vol. 23, No. 2, April 2002 BIOSAFETY CONSIDERATIONS FOR AUTOPSY 109 (62). Nonetheless, strict adherence to Universal Precau- portion of medical students became tuberculin skin test– tions and the additional use of N-95 respirators are rec- positive, and fatal tuberculosis developed in several of ommended (63). them, after the autopsy training period of their curricu- Spongiform encephalopathies such as Creutzfeldt-Ja- lum (84,85). kob disease (CJD) also can be transmitted by percutane- An autopsy is an exceptionally efficient method of ous autopsy exposure. These transmissible dementias are transmitting tuberculosis from the decedent to those caused by infectious isoforms of host membrane sialo- present in the dissection room.
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